Memorandum submitted y the National Black and Minority Ethnic Mental Health Network (MH 23)
1. The BME Network
1.1 The National Black and Minority Ethic Mental Health Network (BME Mental Health Network) is a coalition of organisations and individuals committed to ending the disproportionaly negative experience received by racialised people within the mental health system.
2. The wider context
2.1 The differential impact of the proposed mental health legislation on Black and Minority Ethnic (BME) groups is a well-documented feature of the mental health system. The recently published 'Count me in' Census is the latest in a long line of research highlighting the extent of the disparity. The roots of this disparity are multifactoral. However, of critical importance is the form and operation of mental health legislation. The current legislation may be a factor in producing disparity. The proposed adjustments are an opportunity to reduce disparity.
2.2 Any legislation has to work in the real world. The real world for BME groups is one that ascribes particular characteristics according to ethnicity. This can lead to implicit perceptions of some BME populations as dangerous, unstable and in need of 'management'. Such notions permeate the knowledge and discourse around BME health - mental health in particular. The Macpherson inquiry into the death of Steven Lawrence conceptualised this as 'institutional racism' defined as:
"The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. This can be seen or detected in processes, attitudes, and behaviour that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping which disadvantages people in ethnic minority groups"
Accordingly, BME groups have been variously identified as being genetically predisposed to mental health problems and/or having psychologically destructive familial and cultural norms. This has affected their interaction with services. 'Colour blind' legislation that attempts to ignore this context will perpetuate disparity. Legislation which does not attempt to improve disparities could be argued not to satisfy the Department of Health's duty to promote equality and good race relations under the Race Relations Amendment Act.
2.3 The precise nature of 'mental health' can only be properly understood as socially and culturally rooted concepts of 'appropriate and inappropriate' cognitions, dispositions and behaviours. By extension 'mental illness' is congruent with the particular impression of BME people perpetuated by institutional racism. Discrimination is therefore the default position that must be proactively counteracted by social policy. Indeed, this has been the implication of the Mcpherson inquiry, particularly on the Metropolitan police and other public bodies. The case for a similar response within mental health is now overwhelming.
2.4 The national strategy for addressing discrimination within mental health is the Delivering Race Equality (DRE). During the community consultation events for this strategy, decreased disparity in compulsory admission rates was high on the agenda. The causes of these disparities include differences in pathways to care, the ways that decisions are made by various professionals, social and community support provided to service users, and the operation of current mental health law.
2.5 The DRE strategy is entirely about improving mental health practice. Important as this is, it does not touch the underlying structural dynamics related to compulsory detention that is the domain of mental health legislation. Properly addressing this issue requires a comprehensive approach which deals with both mental health practice and compulsory powers of detention. The effect will be to both address the broader social 'feeders' which generate more aversive pathways into and through the mental health system by BME people, also the operation of legal authority in the detention of those deemed a threat to themselves and/or others.
3. CRITICAL ISSUES - Particular concerns with the amendments to the Mental Health Act (1983)
Definition of mental disorder
3.1 The position of the Government that the proposed definition of mental disorder 'does not widen but merely simplifies the definition' is strongly contested by the BME Network (see BME Network response to the REIA in Appendix 1). The effect of the new definition will be a greater reliance on clinical judgement to establish when a disorder is/is not present. Despite concerns put forward by their own Advisory Group for the Race Equality Impact Assessment of the Bill (two members of the BME Network sat on this group - see Appendix 1) on the likely impact of this change on rates of compulsory detention, the Department of Health has failed even to attempt to demonstrate that the proposed changes will be race neutral. The more one relies on clinical judgement rather than transparent protocol, the more that clinicians rely on instinct rather than science and the more that they fall back on non clinical schema such as stereotypes about ethnic groups. This leads to less accurate and testable diagnoses, moreover, cross cultural validity cannot be assured if there are no criteria or clear professional standards. Without caveats built into the Act requiring clinical judgements to be taken in light of the social and cultural background of patients, the predisposition to conceptualise BME people as mentally disordered will have an increased potential impact on the diagnostic process.
Criteria for detention
3.2 The Network response to the REIA (Appendix 1) details the concerns on the criteria for detention. However, it is important to reiterate that the BME Network proposed that the adjusted definition of mental disorder and changes to the criteria for detention are likely to reinforce each other. The increased subjectivity implicit in 'appropriate treatment', together with the simplified definition of mental disorder will effectively lower the threshold for compulsion, increasing the disproportionate impact of the legislation in its current form.
Supervised Community Treatment
3.3 Though the Network welcomes the narrowing of the SCT proposals to those who have previously been in hospital, there are still concerns around the extension of compulsory powers beyond the hospital setting. The 'Breaking the Circles of Fear' report highlights the degree of alienation between BME people and mental health services.
3.4 Despite the narrowing of the provision for Supervised Community Treatment (SCT), those of Caribbean and African origin are still more likely to be detained using these powers. The Department of Health argues that BME groups should be able to avail themselves of treatment in their own homes, however, it is not clear that BME groups want to avail themselves of compulsory treatment at home. Moreover, given that people from BME groups will disproportionately be treated against their will at home there are questions about how this will be viewed by BME communities. Many already view compulsory treatment in hospital as a form of arrest. Some may view it as a form of "house arrest". This is unlikely to improve race relations.
3.5 There are also questions about whether it is reasonable to treat people at home if their environment and housing is sub-standard. BME groups are more likely to live in poverty and in poor housing. It may be that being treated at home (which is cheaper and so may become the default position for Health Care Trusts), will be less effect for some BME groups because their home environment is less therapeutic.
3.6 None of these issues have been adequately addressed by the proposed amendments.
Network Position on the amendments to the Mental Health Act (1983)
4.1 Racial inequalities in the provision of mental health services are well known. The Mental Health Act must be free of bias and contain within it specific safeguards against cultural misunderstandings, discrimination and racism.
Supervised treatment in the community
4.2 Current evidence suggests that unless the Act is amended to prevent this happening, compulsory treatment in the community would be applied to black people in the community disproportionately. Some of the amendments referred to earlier may alleviate this problem to some extent but specific amendments in relation to supervised treatment in the community should be made too.
4.3 An amendment that makes it legally binding for detaining authority to consult with such persons, community organisations and human rights bodies that have knowledge of patient's social and cultural background.
Skill base of professionals
4.4 In order to work effectively and humanely in a multicultural society where institutional racism is endemic, mental health professionals should have the skill to appreciate (a) cultural diversity in the meaning of `mind' and `mental disorder'; (b) diversity of interventions and therapies appropriate for patients of various backgrounds; and (c) the influence stereotyping arising from sexist and racist perceptions of people held in society.
4.5 where ever the 'Approved Mental Health Professional' (AMU-1P) is mentioned in the course of amendments to the Act, there should be a clause stating that the person should have `those skills that are appropriate for working in a multicultural society'.
4.6 An overriding statement under principles to be adhered to may be an additional safeguard.
Patient safeguards with regard to the Mental Health Review Tribunal
4.7 Tribunal currently fail to protect BME people from unjust sectioning and prolonged detention. The amended Act should make it obligatory for membership of Mental Health Review Tribunal to include people from diverse cultural communities and/or people with knowledge or experience in race relations and anti-discriminatory practice.
4.8 An amendment to Schedule 2 of the 1983 Act should ensure that (a) the legal persons appointed by the Lord Chancellor should have experience in the race relations field; and (b) the non-legal, non-medical persons appointed by the Lord Chancellor should have experience in anti-discriminatory practice.
4.9 An amendment to Section 78 (Procedure of Tribunals) should state that the Tribunal, in arriving at their decision, takes account of cultural diversity and
An amendment to Section 72 (Power of Tribunal) should enable a Tribunal to direct the detaining authority to seek additional information on cultural background of the patient.
Simplified definition of mental disorder
4.10 In a multicultural society there is diversity in the understanding of concepts such as 'mind' and 'mental disorder'. By failing to allow for this the Act as it stands is discriminatory.
An amendment to the Act should bring in a clause that states that the judgment of the presence of 'mental disorder' must take account of the patient's social and cultural background
Exclusion for drug and alcohol dependency and preserve the effects of Act in relation to people with learning disabilities.
4.11 In order to counteract racial bias in the Act there should be exclusions that target misdiagnosis as 'mental disorder' situations where people are merely exhibiting beliefs and/or behaviors that may be culturally appropriate although not recognized as such by mental health professionals.
4.12 An amendment should ensure that (for the purpose of sectioning) mental disorder should not be construed by 'reason only of culturally appropriate beliefs and / or behaviors.'
Availability of appropriate treatment
4.13 For treatment to be effective it must be geared to the needs of the patient concerned. In the case of treatment that is imposed on someone compulsorily, the treatment may amount to 'torture' or be 'inhumane' or degrading treatment in the sense these terms are used in Human Rights Legislation unless it is culturally and socially acceptable to the patient in terms of their cultural background, sexuality etc.
4.14 An amendment should make it legally binding that any treatment that is imposed on a patient should take account of the patient's culture, gender, sexuality and social background.
Remedy ECHR incompatibility in relation to the Nearest Relative and bring Act to be in line with Civil Partnership Act 2004.
4.15 While amending the Mental Health Act so that it is in line with human rights and civil partnerships legislation, by the same token it is necessary to amend it to be in line with the Human Rights Act and the Race Relations Act in both spirit and letter. For this reason an introduction to the Act should set out principles that define human rights and anti discriminatory practice.
4.16 The principles should be modelled on those within the Scottish Mental Health Act 2003, including adherence to equality and non-discrimination.
Over the past few years the BME Mental Health Network has been working with the Department of Health exploring how adjustments to mental health legislation could be achieved without disadvantaging particular ethnic groups. Though sometimes fraught with difficulties and challenges, productive dialogue has been maintained. Members of the Network sat on the Advisory Group that fed into the process of developing the Race Equality Impact Assessment on the 2004 draft bill and on the current amended Mental Health Act. With the amended Act now moving through parliament on its way to becoming law, the current REIA report represents the culmination of the government's efforts to understand and address racial inequality. Considering the information provided by BME service users, academics, professional and a host of other stakeholders, the government's final response outlined in the REIA report is extremely disappointing.
What follows is a detailed critique of the REIA report by the National BME Mental Health Network. This also represents the formal distancing from the REIA report of the Network members (Marcel Vige, Professor Kwame Mckenzie) who sat on the REIA Advisory Group. The expectation that Network input would lead to a more comprehensive, substantive response by government has not been fulfilled.
As things currently stand, the amended Mental Health Act is set to reinforce the entrenched racial bias that characterises the mental health system in the UK. The Network calls on all of the various stakeholders, including the CRE, to do their bit in pushing the government to acknowledge and properly address the issues emerging from REIA consultations, to which the REIA report suggests painfully inadequate remedies, or else dismisses completely.
Co-Chair National BME Mental Health Network
The Response on The National Black and Minority Ethnic (BME) Mental Health Network to the Race Equality Impact Assessment of the proposed amended Mental Health Act.
to be read in conjunction with the REIA Report: http://www.dh.gov.uk/assetRoot/04/14/05/07/04140507.pdf
"The main purpose of a race equality impact assessment is to pre-empt the possibility that your proposed policy could affect some racial groups unfavourably."
[source: Commission for Racial Equality]
1.1 The Race Equality Impact Assessment (REIA) is intended to be a learning process for the government that leads to mechanisms to address possible ethnic bias in the application of policy and legislation. This requires an appreciation of the need to question the government's received wisdom that policy and legislation are somehow 'race neutral'. Indeed, the very reluctance to reconsider - even abandon such pre-existing notions about where discrimination resides feeds institutional racism by relegating remedial action to the periphery, whilst leaving the core issues (basically the really challenging bits) untouched. This clearly applies to the REIA report. The pre-set ideas of the government are as follows:
· The wording of the definition in legislation is neutral. It does not inherently discriminate on the grounds of race. The Department's firm view is that the proposed definition of mental disorder does not widen but merely simplifies the definition. [underlines in original]
· the revised definition of mental disorder does not change its meaning.
· This [ethnic inequality] is best addressed through the guiding principles - including the non discrimination principle - which open the new draft Code of Practice, the actions arising from the REIA and the ongoing work on DRE.
· The Department's view is that any changes to patterns of detention will not be significant. [The network believes this illustrates a critical flaw with the government's approach. If there is no significant change in the current pattern of detention, BME people will continue to be over-represented. This represents a failure to 'eliminate unlawful racial discrimination, promote equality of opportunity, promote good relations between people of different racial groups' as required by the Race Relations Amendment Act.]
[source: REIA 2006]
Approaching the REIA from this position implies that there is no need to alter core legislation in the interests of race equality. As such, in so far as the REIA is performed on the core legislation (specifically the proposed amendments), it was always doomed to fail.
2. The Network's view
2.1 The separation of legislation and practice, 'locating' systemic discrimination within the latter grossly simplifies and distorts the issue. We believe discrimination arises from the interaction between both. Legislation sets the parameters for professional conduct. It also establishes an overall context within which notions of 'normal', 'appropriate' behaviour are established. Legislation also has a powerful symbolic value, reflecting the priorities of the government and the mood of wider society. The artificial distinction between legislation and practice ignores these issues. As such, the REIA report is based on a contrived premise rather than a valid reflection of mental health law as applied to BME communities. The racialised environment within which mental health legislation is both developed and administered reinforces the case for remedial measures within core legislation.
2.2 In purely practical terms, even if one were to accept the government's present position that mental health legislation is somehow 'race neutral', this would not preclude the possibility/desirably of locating anti-discrimination measures within core legislation. If this is the most effective way of addressing ethnic bias within secure mental health settings (which the Network believes is the case), then it should be pursued. The lack of consideration of such an approach within the REIA report suggests that the government's position is more ideological than pragmatic.
2.3 The assumption that racial disparity is not about the Act itself leads to inappropriate interpretations of the evidence collected. This effectively confounds/invalidates the REIA.
3. Definition of Mental Disorder and Criteria for Detention
3.1 Regarding the change in definition, the REIA report states the following: "The Department's firm view is that the proposed definition of mental disorder does not widen but merely simplifies the definition." [underlines in original]. As with the splitting of legislation from practice referred to above, no evidence is presented to support this position. More fundamentally, it is a misrepresentation of the issue as argued by the BME network and others. Where, as is the case with the government's position, simplifying the definition means the removal of qualifying caveats and lowering the threshold at which the definition could be applied, the cohort of people to whom the definition could be applied is inevitably widened. Based on what is already known about the disproportionate impact of the legislation, BME people are likely to be over-represented in this wider cohort. If it is felt that there is a possibility of 'mistakenly identifying' mental disorder in relation to BME people (REIA, Executive summary, page 15), a looser framing of the definition puts even greater reliance on clinical judgements, which have been found wanting in the past. It is issues such as this that the REIA should detect and respond to.
3.2 To the extent that the REIA report acknowledges the increased scope-of-capture of the definition, it points out the following - "As now, it will be for clinicians to use their professional skills and judgement to diagnose the presence of mental disorder. The wording of the definition is race neutral. It does not inherently discriminate on the grounds of race, and is therefore capable of being applied in a way that avoids any such discrimination, provided that diagnosis takes full account of all the patient's circumstances including their social and cultural background" (REIA 2006). This approach of relying on clinical judgement mediated by training is (as indicated by the phrase 'as now') the same approach pursued throughout the history of Mental Health services, during which time disporportionality has persisted. It is well known that judgements about 'mental illness' are not based on objective criteria - they always involve value judgements, hence there is a necessity to regulate the way these judgements are made in order to minimise injustice. This reinforces the argument for a more robust response. Given the increased scope-of-capture ushered in by the amendments, the need is all-the-more pressing.
4. Criteria for detention
4.1 The REIA report refers to the strong view emerging through consultations that the appropriate treatment test is too imprecise. Also referred to is the emergent view that 'in conjunction with the removal of categories of disorder, appropriate treatment will lead to a lower threshold for detention'. On this issue the Mental Health Alliance states the following:
Under current law there needs to be a direct health benefit to all patients on renewal of a section and to some patients at the outset of a section 3 order. The concept of 'appropriate treatment' 'in all the circumstances of the case' even if further defined in a Code of practice is not sufficiently precise. Wherever wider discretion is introduced, there is a risk that biases/prejudices already existing in practice will persist, and tighter wording is needed to be in place to prevent this.
[Source: MHA 2006]
4.2 In addition to the lack of agreement with this position, the government also suggests that 'appropriate treatment could benefit BME patients because clinicians will also be required to consider, amongst other factors, whether the treatment available is culturally appropriate'. There are two problems with this position. Firstly it dismisses rather than addresses the very real concerns regarding appropriate treatment leading to the lower threshold for detention. Secondly it implies that, as a 'trade off' for having 'culturally appropriate' treatment, the shift to the more imprecise language of 'appropriate treatment' is required. The position of the Network is that the provision of culturally appropriate treatment should be an absolute requirement on all clinicians regardless of whether the criteria is the current treatability test or the proposed 'appropriate treatment' approach. This reinforces the argument for principals of non-discrimination (which would be an implicit requirement to provide culturally appropriate treatment regardless of the overall treatment criteria) on the face of the act. The provision of culturally appropriate services should in no way be contingent on the adoption of any particular detention criteria.
5. Supervised Community Treatment (SCT)
5.1 The REIA report details concerns around SCT. Concerns centre on the likelihood of racialised perceptions leading to the application of SCT on BME people where clinicians feel the individual does not merit detention. By virtue of extending compulsory powers under the amended Act, with the absence of robust anti-discrimination mechanisms, this is effectively an extending of the factors currently leading to disproportionate sectioning. The REIA also refers to the increased alienation of BME communities from services as a likely outcome of the disproportionate impact of SCT. Though the government seeks to respond to these issues through 'ongoing training of practitioners' and reflection of concerns in the Codes of practice, this is insufficient as a counter-balance to the anticipated disproportional impact. Unless such measures are part of a more comprehensive package of measures, they are likely to be ineffective.
5.2 The degree to which this extension of compulsory powers into communities will impact on BME communities, notwithstanding any achievements that may be made by strategies such as Delivering Race Equality, necessitates setting down a principle of non-discrimination applicable to the whole of the Mental Health Act. However, the Network's position is that SCTs should be scrapped. The issue of 'revolving door' patients, a large part of the government's justification for SCTs, should be dealt with by improving the quality of services rather than extending compulsory powers beyond the hospital environment.
6. Professional Roles
6.1 The Network is happy with the treatment of this issue within the REIA report.
7. Mental Health Review Tribunals
7.1 The Network is happy with the treatment of this issue within the REIA report.
8. Nearest Relative
8.1 The Network is happy with the treatment of this issue within the REIA report.
9.1 The Network is happy with the treatment of this issue within the REIA report.
10. Code of Practice
10.1 The report makes clear that in-so-far as remedial measures are suggested, they are located within the Codes of Practice. The report also refers to the impact of 'Munjas' on the status of the Code of Practice. Despite the Lords ruling that "great weight" must be given to the code of practice and the requirement that practitioners must "have due regard to it", it does not follow that addressing the problems of the amended Act are best dealt with by the Code. Many of the problems referred to above cut to the substance of the proposed amendments. Where this is the case the government has selected a particular interpretation of the issue (e.g. the separation of legislation and practice to locate discrimination within the latter), or else rejected the concerns raised within the REIA consultation. Ideally the Codes of Practice would support and refine adjustments within the Act that would properly mitigate against racial bias in the use of compulsory powers. The lack of such a comprehensive response by the government fatally undermines the REIA as a means of dealing with the potential for racial bias.
11. Action Points
11.1 Regarding the issues-of-concern raised in the REIA, actions referred to in the report centre on monitoring/research, training and information provision. The only direct policy adjustment is a clause stating that 'AMHPs must always act on behalf of a local Authority, to emphasis their independence from assessing doctors'. The Network's view is that this is entirely inadequate to address the fundamental problems with the amendments, and the Act more broadly.
12.1 The REIA was never established as a means of tackling ethnic bias in the operation of the entire Act. The intention was to impact assess the proposed amendments. Additionally, the amendments themselves were not conceived as a means of addressing discrimination emerging from the use of the Act. Consequently, the potential of the REIA to address the overrepresentation of racialised groups subject to compulsion was always limited. This is perhaps not surprising given the government's rejection of the possibility that institutional racism manifests through the interaction of legislation and practice, requiring remedial adjustments within both domains. The Network is therefore disappointed that the limited opportunity presented by the REIA has been lost. Moreover the Network believes that the report does not conform to the spirit or letter of what constitutes an REIA as detailed by the Commission for Racial Equality. By rejecting direct adjustment of the proposed amendments - even the incorporation of a principal of equality within the Act itself, there is a consistent failure to avert the anticipated negative consequences of the amendments. In sum, the REIA fails as a means of stimulating mental health legislation fit-for-purpose in face of an increasingly diverse population in the 21st century. As such, it represents a regressive rather than progressive step in tackling racial bias within the mental health system.
BME NETWORK MEETING - AMENDMENTS TO
THE ACT 1983
Friday, 12th May 2006 at Greater London Authority, City Hall, The Queen's Walk,
Potential Outcomes under the Proposed
Amendments to the Mental Health Act 1983
Scenarios prepared by
Dr Suman Fernando
D is a tall black man in his late seventies. After being stopped and searched several times, D felt persecuted by the police for many years during his forties and fifties. D was apprehended for allegedly attacking a policeman, diagnosed with 'schizophrenia' and kept in hospital on Section 37 for ten years until he was sixty-five. After that he was allowed to live in the community but recalled to hospital if he refused depot medication. He had been looking after himself in his own council flat for five years. Although feeling people were against him he was involved in local politics having stood as a conservative candidate in local elections. D was asthmatic, had breathing difficulties because of emphysema and severe arthritis of his knees. He walked slowly with a stick having to stop after four or five steps to gain his breath.
D applied for absolute discharge from Section 37 several times without success. The RMO usually objected on the grounds that he was a `schizophrenic' who posed a threat to the public. At the Tribunal hearing, the RMO pointed to D's size in justifying the contention that he was a threat although severely disabled by illness.
Potential Outcomes under the proposed amendments to the Mental Health Act 1983
D may well be discharged if:
(a) the -RMO had been trained to recognise the extent to which the stereotype 'big black and dangerous' was affecting the judgement (s)he made; and / or
(b) the Tribunal had a member who had proper training to recognise racist stereotyping; and / or
(c) the Tribunal had a legal duty to take account of cultural diversity and institutional racism.
Under an amended Act, D may well be kept in supervised treatment in the community. If so he may get justice only if the Act is amended also so that it is legally binding for the detaining authority to consult with community organisations and human rights bodies before presenting reports.
· Scenario Two
M was an Asian Muslim woman who lived with her husband and child of two in a one-bedroom flat. A mental health assessment was requested because M would not allow the child to go to nursery and was hostile to neighbours. Her husband said the he thought she was 'mad' because she did not like her (Asian) neighbours and thought that people were against her. The psychiatrist who was called in deduced that M was suffering from paranoia and may be a risk to her daughter. She was admitted under Section 2 and then 3 and her child was taken into care. Six months later M was still in hospital, quiet and subdued by medication. Her husband had a new `wife'. It transpired that M had been frightened to tell anyone about her suspicions about her husband's infidelity, apparently supported by some neighbours who were related to him.
Potential outcomes under the proposed amendments to the Mental Health Act 1983
This injustice in sectioning may be avoided if the Act is amended so that:
(a) there is a legal obligation for the skill base of professionals to include the skill to appreciate sexist and racist ('Asian woman') stereotyping; and / or
(b) the judgement of 'mental disorder' must take account of a patient's social and cultural background; and / or
(c) the availability of culturally appropriate treatment is necessary for a patient to be sectioned.
The irretrievable position whereby six months medication caused serious damage before the true situation was found out may be avoided if the Act is amended so that
(a) it is legally binding for any treatment that is imposed on a sectioned patient to takes account of a patient's culture, gender, and social background and / or
(b) Tribunals have to do likewise.
· Scenario Three
A was a Chinese man who was seeking asylum in the UK, He was apprehended by the police when neighbours reported him as having shouted at them and run away from his lodgings. When brought to hospital under Section 136 and interviewed with an interpreter, he was agitated, expressing fears of being kidnapped for slavery. Diagnosed as 'schizophrenic', he was medicated and later kept in seclusion. His physical condition deteriorated and when taken out of seclusion he stopped eating. He was given ECT with 'good response' in that he was eating again He then absconded from hospital and was found murdered several months later.
Obviously, A had 'treatment' that worsened his distressed state. Also, he should never have been sectioned but instead helped with social care.
Potential outcomes under the proposed Amendments to the Mental Health Act 1983
This scenario may be different of the Act is amended so that:
(a) the judgement of 'mental disorder' being present takes account of social and cultural background; and / or
(b) skill base of professionals involved has to include skills to work in a multicultural society; and / or
(c) mental disorder is not construed for the purpose of sectioning by reason only of culturally appropriate beliefs and I or behaviours.
· Scenario Four
S was a young black woman aged 25 who lived with her family in a largely white neighbourhood. She fell out with her parents, who she claimed pretended to be white, and moved to a different area. After a fire in her flat, S was arrested and charged with arson. Psychiatric examination resulted in a diagnosis of `schizophrenia' and drug abuse with bizarre behaviour and paranoia and thought disorder. S was sent to a secure unit and given high doses of medication for long periods because she proved `treatment resistant'. She applied to Tribunals several times but was not discharged. Many years later it transpired that S had never taken illicit drugs but was a deeply religious person. At the time of being when arrested, she was seeing a healer and taking calming tablets from a chemist. The fire was an accident resulting from lack of sleep when she was depressed.
Potential outcomes under the proposed amendments to the Mental Health Act 1983
If the Act had been different, S may have received the help she deserved and not suffered gross injustice. To enable this the Act should be amended to make it legally binding
(a) for skill base of professionals to include adequate skills to work in a multicultural society; and ! or
(b) for any treatment imposed to be culturally and socially appropriate and beneficial to the patient.
· Scenario Five
M was a 50 year old black African woman who lived with her white English husband in South London. There was an ongoing conflict with a white neighbour who she alleged was casting spells on her by making peculiar noises. When her husband developed incurable cancer she nursed him at home without any help from nursing services until he died. A week later her neighbour called the police claiming that she threw paraffin at him. She was arrested and charged with attempted arson. A psychiatrist diagnosed paranoid schizophrenia basing his judgement mainly on the police records that listed various complaints made by M about the neighbour that the police had found unjustified. She was treated with a variety of drugs and finally 'stabilised' on a fairly high dose of depot medication, although the 'paranoia' was deemed 'resistant to treatment'. Applications to Tribunals were unsuccessful. Finally she was sent on leave with the warning that she would be recalled if she failed to take the depot medication. An independent psychiatrist felt that M may have been depressed after bereavement, her belief in a neighbour casting a spell was consistent with cultural belief about someone who obviously disliked her, and that police records were a demonstration of discriminatory reporting.
Potential Outcomes under the proposed amendments to the Mental Health Act 1983
The injustice in this instance may be prevented if the Act is amended:
(a) to ensure that the Tribunal included people who have knowledge and experience in anti-discriminatory practice; and / or
(b) the Tribunal had to take account of cultural diversity in the way mental distress is expressed; and / or
(c) skills of professionals involved had to be appropriate for a multicultural society
· Scenario Six
C was a Turkish man in his early twenties who had arrived in UK with his parents seeking asylum. They had fled after close relatives had been arrested and tortured. He lived in a hostel having become homeless after falling out with his parents. C was arrested for allegedly stalking an older white woman. While on remand in prison, C became very distressed. Psychiatric examination concluded 'schizophrenia' with delusions that the, woman concerned was trying to torture him with electricity and trying to sell his kidneys. After two years in a medium secure unit C applied unsuccessfully to a Tribunal for discharge. Although not voicing any 'delusions' C was deemed a potential threat in the community and unrealistic in outlook because he planned to marry someone in Germany.
In this instance an independent psychiatrist found that C's parents were worried that C may be at risk of being forced to have a kidney removed and they had planned a marriage to a German resident. They appreciated how terrified he must have been when sent to prison in UK. A second Tribunal one year later still did not discharge C.
Potential Outcomes under the proposed amendments to the Mental Health Act 1983
The failure by the system to take into account C's experiences in Turkey, effect of imprisonment and culturally appropriate beliefs and behaviour may be avoided if the Act is amended so that:
(a) Tribunals have to take account of the patient's background, culture and social experiences; and / or
(b) professionals have to be sufficiently skilled in order to be allowed to be involved in sectioning people from a variety of cultural backgrounds; and / or
(c) the judgement of 'mental disorder' being present must take account of cultural and social background and / or
(d) 'mental disorder' is never diagnosed when it is based merely on culturally (and socially) appropriate beliefs and behaviour.
 Healthcare Commission. Count me in census 2006. London: HC, 2007. www.healthcarecommission.org.uk/_db/_documents/Count_Me_In_2006.pdf
Bhui K, Stansfeld S, Hull S, Priebe S, Mole F, Feder G. Ethnic variations in pathways to and use of specialist mental health services in the UK: systematic review. Br J Psychiatry 2003;182:105-16.
 Macpherson W. The Stephen Lawrence inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: Stationery Office, 1999.
 Sainsbury Centre for Mental Health, 'Breaking the Circles of Fear', 1992. SCMH